Deficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
35% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Census: 68
Deficiencies: 2
Date: Nov 20, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to administer oxygen as ordered to a resident and concerns about inaccurate nurse staffing postings and staffing shortages.
Complaint Details
The complaint investigation found that resident #510 was not administered oxygen as ordered despite physician orders and documentation. Interviews with staff confirmed the resident was not on oxygen. Additionally, staffing postings were inaccurate with discrepancies in hours worked, and residents reported concerns about short staffing and long call light wait times.
Findings
The facility failed to ensure that one sampled resident (#510) received oxygen as ordered, despite physician orders and documentation indicating oxygen administration. Additionally, the facility failed to maintain accurate daily nurse staffing postings, with discrepancies between scheduled and actual hours worked, and residents reported concerns about staffing shortages and long wait times for care.
Deficiencies (2)
Failure to provide safe and appropriate respiratory care by not administering oxygen as ordered to resident #510.
Failure to ensure accurate and complete daily nurse staffing postings, resulting in discrepancies between scheduled and actual hours worked.
Report Facts
Oxygen order flow rate: 2
Oxygen titrate flow rate: 5
CNA workload: 28
RN hours discrepancy: 4.58
Facility census: 68
RN hours per resident per day: 23
National average RN hours per resident per day: 28
Arizona average RN hours per resident per day: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) Staff #61 | Interviewed regarding oxygen administration process and confirmed resident was not on oxygen | |
| Licensed Practical Nurse (LPN) Staff #113 | Interviewed about oxygen administration process and risks of non-administration | |
| Assistant Director of Nursing (ADON) Staff #76 | Verified oxygen orders and charting, discussed risks of non-administration | |
| Certified Nursing Assistant (CNA) Staff #39 | Interviewed about staffing workload and weekend staffing | |
| Staffing Coordinator Staff #31 | Interviewed about staffing calculations, discrepancies, and census | |
| Administrator Staff #83 | Interviewed about staffing concerns, complaints, and CMS staffing rating |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Sep 15, 2023
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements and ensure the facility meets healthcare standards.
Findings
The facility was found deficient in multiple areas including failure to implement a complete care plan for bathing for one resident, failure to provide appropriate treatment and care according to orders for another resident resulting in a critical lab value not being acted upon, unsafe chemical storage in the kitchen, and improper food storage practices.
Deficiencies (4)
Failure to develop and implement a complete care plan for bathing for resident #17.
Failure to provide appropriate treatment and care according to orders for resident #215, including failure to notify provider or pharmacy of critical vancomycin lab results.
Failure to ensure chemicals were safely stored in the kitchen, with chemicals stored on an open shelf and kitchen door left open.
Failure to properly store food, including uncovered or unsealed food items in the walk-in refrigerator and freezer.
Report Facts
Vancomycin serum trough level: 49.6
Vancomycin administration dates: 7
Discard date: 2023
Quantity of hash browns: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #7 | MDS Coordinator | Interviewed regarding lack of bathing care plan for resident #17 |
| Staff #12 | Director of Nursing | Interviewed regarding bathing care plan and vancomycin trough monitoring |
| Staff #60 | Licensed Practical Nurse | Interviewed about vancomycin trough monitoring and notification procedures |
| Staff #102 | Assistant Director of Nursing | Interviewed about vancomycin trough monitoring and pharmacy coordination |
| Staff #11 | Dietary Supervisor | Interviewed about chemical and food storage practices |
| Staff #84 | Staff written up for failing to confirm lab values prior to medication administration | |
| Staff #188 | Administrator | Interviewed about chemical and food storage policies and supervision |
Inspection Report
Routine
Deficiencies: 4
Date: Sep 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, medication management, safety, and food storage at Alta Mesa Health and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to implement a care plan for bathing for one resident, improper monitoring and notification of critical vancomycin lab levels resulting in a resident's death, unsafe chemical storage in the kitchen, and improper food storage practices that could affect food quality.
Deficiencies (4)
Failure to develop and implement a complete care plan for bathing for one resident (#17).
Failure to provide appropriate treatment and care according to orders and professional standards for resident (#215), including failure to notify provider or pharmacy of critical vancomycin lab results.
Failure to ensure chemicals were safely stored in the kitchen, with chemicals stored on an open shelf and kitchen door left open.
Failure to properly store food in the kitchen, including uncovered or unsealed food items and food with holes in coverings.
Report Facts
Vancomycin serum trough level: 49.6
Vancomycin administration dates: 7
Discard date: 2023
Spray bottle volume: 3
Spray bottle volume: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #7 | MDS Coordinator | Interviewed regarding care plan for bathing for resident #17 |
| Staff #12 | Director of Nursing (DON) | Interviewed regarding bathing care plan and vancomycin lab notification for resident #215 |
| Staff #60 | Licensed Practical Nurse (LPN) | Interviewed regarding vancomycin trough monitoring and notification procedures |
| Staff #102 | Assistant Director of Nursing (ADON) | Interviewed regarding vancomycin trough monitoring and notification procedures |
| Staff #11 | Dietary Supervisor | Interviewed regarding chemical and food storage practices |
| Staff #84 | Nursing Staff | Written up for failure to confirm lab values prior to medication administration |
| Administrator #188 | Administrator | Interviewed regarding chemical and food storage policies and supervision |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 4, 2022
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to properly screen and hire staff with prior disciplinary actions, failure to complete required PASARR screenings for certain residents, and medication administration errors.
Complaint Details
The complaint investigation substantiated that the facility failed to properly screen and hire staff with prior disciplinary actions, failed to complete required PASARR screenings, and had medication administration errors exceeding acceptable rates.
Findings
The facility failed to ensure a Certified Nursing Assistant with a prior abuse/neglect disciplinary action was not hired, failed to complete or update PASARR screenings for residents staying longer than 30 days, and failed to administer medications according to physician orders, resulting in an 8.57% medication error rate.
Deficiencies (5)
Failure to ensure a Certified Nursing Assistant was not hired with a finding of resident abuse or neglect from the State professional licensing board.
Failure to develop and implement policies and procedures to prevent abuse, neglect, and theft, specifically failing to implement hiring policy for a CNA with prior disciplinary action.
Failure to ensure PASARR screening was completed for one resident and updated for two residents who remained in the facility longer than 30 days.
Failure to ensure medication administration met professional standards of quality for two residents, including administering medications not as prescribed.
Failure to ensure medication error rates were not 5 percent or greater, with an error rate of 8.57% due to incorrect medication administration for one resident.
Report Facts
Medication error rate: 8.57
Medication error rate threshold: 5
Hire date: Jun 20, 2022
Certification expiration date: Jul 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) staff #3 | Named in deficiency for being hired with prior disciplinary action for abuse/neglect | |
| Director of Nursing (DON) staff #48 | Interviewed regarding hiring process and medication administration findings | |
| Human Resources Director staff #20 | Interviewed regarding certification verification and hiring process | |
| Executive Director (ED) staff #66 | Interviewed regarding hiring process and notification of disciplinary actions | |
| Licensed Practical Nurse (LPN) staff #106 | Observed administering medication and interviewed about medication administration | |
| Licensed Practical Nurse (LPN) staff #110 | Observed administering medication and interviewed about medication errors | |
| Activities/Social Services Supervision staff #54 | Interviewed regarding PASARR screening process |
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